{"id":897,"title":"Overseas Mediclaim Insurance Policy Proposal Form","purpose":"proposal","insurer":{"slug":"national-insurance","name":"National Insurance Company Limited"},"source_pdf":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/OMP%20B%26H%20-%20Proposal%20Form.pdf","sha256":"c0487d04a47f98c1c26a3548d0422b80352d5b80dbbefaffd8798e273f795f52","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals (proposers) applying for Overseas Mediclaim Insurance coverage for business or holiday travel abroad.","notes":["Fill the form in BLOCK LETTERS.","Do not leave medical history questions blank; answer Yes or No.","Photograph must be stamp sized and signed beside it.","If the form is filled by a representative, proposer must sign the certificate section.","Annexure I must be completed by an M.D. doctor only.","Use original documents and reports as required.","Section 41 of Insurance Act prohibits rebates."],"title":"Overseas Mediclaim Insurance Policy Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer details","fields":[{"help":"Enter full name exactly as in passport","type":"text","label":"Name of the Proposer (as in passport)","options":[],"required":true,"pdf_field":""},{"help":"Enter full residential address","type":"text","label":"Home Address in India","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"District","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Postal Index Number","type":"number","label":"PIN","options":[],"required":true,"pdf_field":""},{"help":"Include STD code if applicable","type":"phone","label":"Telephone","options":[],"required":false,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"E -Mail","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Occupation","options":[],"required":true,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"PAN","options":[],"required":false,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"Date of birth (as in passport)","options":[],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender (M/F)","options":["M","F"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Blood group","options":[],"required":false,"pdf_field":""},{"help":"Height in centimeters","type":"number","label":"Height (cms)","options":[],"required":false,"pdf_field":""},{"help":"Weight in kilograms","type":"number","label":"Weight","options":[],"required":false,"pdf_field":""},{"help":"Passport number","type":"text","label":"Passport No.","options":[],"required":true,"pdf_field":""},{"help":"Passport expiry date","type":"date","label":"Date of expiry","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Passport issuing office","options":[],"required":false,"pdf_field":""},{"help":"Start date of insurance coverage","type":"date","label":"Period of Insurance (from)","options":[],"required":true,"pdf_field":""},{"help":"Total number of days insured","type":"number","label":"No. of days","options":[],"required":true,"pdf_field":""},{"help":"List countries, days of stay, and visa type","type":"text","label":"Countries to be visited","options":[],"required":true,"pdf_field":""},{"help":"Tick one purpose","type":"choice","label":"Purpose of visit (please tick √)","options":["Business","Holiday","CFT"],"required":true,"pdf_field":""},{"help":"Select one plan type","type":"choice","label":"Type of plan (B&H)","options":["Asia (excl Japan)","Worldwide (excl USA/ Canada)","Worldwide (incl USA/ Canada)"],"required":true,"pdf_field":""},{"help":"Sum Insured in US dollars","type":"amount","label":"SI opted for","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the family medical practitioner","options":[],"required":false,"pdf_field":""},{"help":"Address of medical practitioner","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"Phone number of medical practitioner","type":"phone","label":"Contact no.","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name in Bank Account","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Bank Branch","options":[],"required":false,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Account no","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"MICR Code","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"IFSC Code","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Photograph and Signature","fields":[{"help":"Paste one stamp sized photograph","type":"photo","label":"Photograph","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer or guardian if minor"},{"title":"Medical history of Proposer or Insured person","fields":[{"help":"Answer Yes or No","type":"yes-no","label":"Are you in good health and free from physical and mental disease or infirmity","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"Have you ever suffered from any illness or disease up to the date of making this proposal","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"Do you have any physical defect or deformity?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"Have you ever been admitted to any hospital/ nursing home/clinic for treatment or observation","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"Have you suffered from any illness/disease of had an accident in the 12 months preceding the first day of insurance","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide full details if any answer above is Yes","type":"text","label":"If answer is ‘Yes’ to any of the foregoing questions please give full details as under: Nature of illness/ medical disease/injury & treatment received, Date on which first treatment taken, First treatment completed/ is continuing, Name of attending Medical practitioner / surgeon with his address and telephone","options":[],"required":false,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"Have you any intention of engaging in professional sports?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if intending to engage in professional sports","type":"text","label":"If ‘Yes’, give details","options":[],"required":false,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Please give details of any knowledge of any positive existence of any ailment, sickness or injury which may require medical attention whilst on tour abroad.","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Medical reports submission","fields":[{"help":"Indicate if ECG report is submitted","type":"yes-no","label":"ECG","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if fasting blood sugar report is submitted","type":"yes-no","label":"Fasting blood sugar","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if urine strip test report is submitted","type":"yes-no","label":"Urine strip test","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if any other medical test report is submitted","type":"yes-no","label":"Any other test","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Print name in block letters","type":"text","label":"Name of the Proposer (in BLOCK LETTERS)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Certificate from proposer if form filled by representative","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Print name in block letters","type":"text","label":"Name of the Proposer (in BLOCK LETTERS)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Annexure I - To be completed by the Doctor","fields":[{"help":"Answer Yes or No","type":"yes-no","label":"Does the urine Strip Test show any sugar?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Doctor's signature","type":"signature","label":"Signature of the Doctor","options":[],"required":true,"pdf_field":""},{"help":"Doctor's full name","type":"text","label":"Name of the Doctor","options":[],"required":true,"pdf_field":""},{"help":"Doctor's qualifications","type":"text","label":"Qualifications","options":[],"required":true,"pdf_field":""},{"help":"Doctor's address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Doctor's contact number","type":"phone","label":"Telephone No.","options":[],"required":true,"pdf_field":""}],"filled_by":"doctor (M.D. only)"}],"deadlines":[],"applies_to":"Overseas Mediclaim Policy for Business & Holiday","attachments":["One stamp sized photograph","Medical reports if required (ECG, fasting blood sugar, urine strip test, other tests)","Electrocardiogram and Stress Test report if applicable"],"declarations":["I will not travel against physician's advice.","I am not on any medical treatment waiting list.","I will not travel to obtain medical treatment.","I have not received a terminal prognosis before this date.","The information given is true and complete to the best of my knowledge.","I will notify any change in occupation or health before risk acceptance.","I consent to the company seeking medical and insurance information for underwriting and claims.","I authorize sharing of my proposal and medical records with regulatory authorities."],"dropped_labels":15},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"email","value":"customer.support@nic.co.in","label":"Customer Support Email","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/","quote":"National Insurance Company Limited: Trusted Since 1906\nSkip to main content\nToll-Free 18003450330\ncustomer.support@nic.co.in\nSearch\nSkip to main content\nbhashini\nAccessibility Options\nAccessibility Options\nReset\nHigh Contrast\nInvert\nSaturation","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"18003450330","label":"Toll-Free","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/","quote":"National Insurance Company Limited: Trusted Since 1906\nSkip to main content\nToll-Free 18003450330\ncustomer.support@nic.co.in\nSearch\nSkip to main content\nbhashini\nAccessibility Options\nAccessibility Options\nReset\nHigh","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"033-22022100","label":"Head Office Telephone","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/","quote":"d and Head Office\nPremises No. 18-0374, Plot No. CBD-81,\nNew Town, Kolkata-700156\nCIN: U10200WB1906GOI001713\nTelephone: 033-22022100\nFacebook\ninstagram\nX (Twitter)\nyoutube\nlinkedin\nWhatsapp\nBEWARE OF SPURIOUS PHONE CALLS AND FICTITIOUS /FRAUDULENT OFFE","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"9920501906","label":"WhatsApp Us","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/contact-us","quote":"h Us For Answers And Assistance—Your Gateway To Communication With Our Team.\nCustomer Service\n1800 345 0330\nWhatsApp Us\n9920501906\nHead Office\nPremises No. 18-0374, Plot No. CBD-81, New Town,  Kolkata - 700156\nTelephone: 033-22022100\nNote: Official c","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"address","value":"CRM Dept., National Insurance Co. Ltd., Premises No. 18- 0374, Plot no. CBD-81, New Town, Kolkata - 700156","label":"Grievance Redressal Postal Address","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/Rajrajeshwari%20Freedom_CIS_Revised_Grp.pdf","quote":"e: https://nationalinsurance.nic.co.in/en/grievance Toll free: 1800 345 0330 E-mail: customer.relations@nic.co.in Post: CRM Dept., National Insurance Co. Ltd., Premises No. 18- 0374, Plot no. CBD-81, New Town, Kolkata - 700156 Insurance Ombudsman – As per Appendix attached to Policy. | 7\n12. | Things to Remember | Implied renewability (except o","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"customer.relations@nic.co.in","label":"Grievance Redressal Officer Email","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/National%20Suryoday%20Policy%20-%20CIS.pdf","quote":"Details of Grievance redressal officer: Website: https://nationalinsurance.nic.co.in/ Toll free: 1800 345 0330 E-mail: customer.relations@nic.co.in Phn: (033) 25370070 Post: National Insurance Co. Ltd.,\nPremises No. 18-0374, Plot no. CBD-81, New Town, Kolkata – 70015","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800 345 0330","label":"Grievance Toll free","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/National%20Suryoday%20Policy%20-%20CIS.pdf","quote":"holders Protection | • Details of Grievance redressal officer: Website: https://nationalinsurance.nic.co.in/ Toll free: 1800 345 0330 E-mail: customer.relations@nic.co.in Phn: (033) 25370070 Post: National Insurance Co. Ltd.,\nPremises No. 18-0374, Plot","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"url","value":"https://nationalinsurance.nic.co.in/en/grievance","label":"Grievance Website","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/Rajrajeshwari%20Freedom_CIS_Revised_Grp.pdf","quote":"ice\n11. | Grievances/ Complaints | In case of any grievance the insured person may contact the company through Website: https://nationalinsurance.nic.co.in/en/grievance Toll free: 1800 345 0330 E-mail: customer.relations@nic.co.in Post: CRM Dept., National Insurance Co. Ltd., Premises No","fetched_at":"2026-10-20"}],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/national-insurance/897-overseas-mediclaim-insurance-policy-proposal-form"}